— 照護管理 · EASY · MCQ —
護理師向一位新診斷為心臟衰竭的病人提供出院指導，應包含哪項有助於管理體液的指導？
A nurse is providing discharge instructions to a client with newly diagnosed heart failure. Which instruction should the nurse include to help manage fluid volume?
- ADrink plenty of fluids攝取大量液體
- BWeigh yourself daily at the same time each morning✓ 正解每天早晨同一時間測量體重
- CReport any swelling in your feet報告任何腳部腫脹
- DIncrease your salt intake增加鹽分攝取
— Explanation · 中文詳解 —
心臟衰竭（Heart Failure, HF）病人因心臟泵血功能受損，極易出現體液滯留。每日在同一時間、穿著相同重量衣服量體重，是監測體液平衡最敏感的指標。體重短期內快速增加（如 24 小時內增加 >2 磅或一週增加 >5 磅）是病人體液滯留的警訊，需儘早調整利尿劑或就醫。這是居家自我照護中最具臨床價值的指標。
Heart failure patients are at high risk for fluid retention. Daily weights at the same time each morning, wearing similar clothing, is the most sensitive indicator of fluid balance. A weight gain of more than 2 lb in 24 hours or more than 5 lb in a week signals fluid overload requiring diuretic adjustment or medical evaluation.